Endoscopic Scores in chronic inflammatory bowel disease
Thomas Klag and Martin Goetz , Tübingen
IntroductionChronic inflammatory bowel disease (IBD) with its two forms, Crohn’s Disease (CD) and Ulcerative Colitis (UC), can be classified by various endoscopic scores with regards to endoluminal inflammatory activity of the diseases. Therefore, endoscopy is a central part of the diagnostic work-up for treatment decisions and guidance of therapy (e.g. by assessment of treatment response) (1). In CD and UC, different scores have been established. The aim of using these endoscopic scores is to achieve some degree of objectivity and comparability. Certainly, individual assessment of inflammatory features – mucosal reddening, for example – is dependent on subjective evaluation. The scores nevertheless are important in the setting of studies to provide a standardized basis for assessment (2). Classification according to pattern and localization of involvement is not the topic of this report – for that, see terminology projects such as the most recent one by the German society DGVS (3).
Endoscopic Scores – Crohn’s DiseaseThe so-called “Crohn’s Disease Endoscopic Index of Severity” (CDEIS) was the first endoscopic activity index for CD, but it was less suitable for everyday practice due to its complexity. Therefore, an easier to use version was developed: the “Simple Endoscopic Score for Crohn’s Disease” (SES-CD) (4). This score is based on the evaluation of five defined bowel segments (rectum, sigma + descending colon, transverse colon, ascending colon, and terminal ileum), and in these segments the presence and size of ulcerations and the extent of the inflammatory area and stenosis are assessed, then classified in severity as a score of 0–3. The scores for each individual segment are added together as a sum score (see Table 1) (4).
Table 1: “Simple Endoscopic Score for Crohn’s Disease” (SES-CD) (4).
|Ulcerations||none||aphtoid <0,5cm||0,5 – 2cm||>2cm|
|Ulcerated surface||none||<10%||10 – 30%||>30%|
|Inflamed surface||none||<50%||50 – 75%||>75%|
|Stenosis||none||single, passable||multiple, passable||not passable|
Examples are shown in Figures 1a–d.
Abb. 1: SES-CD:
- a) SES-CD-Ulceration 1: aphthous lesion term ileum
- b) SES-CD-Ulceration 3: Ulceration > 2 cm term. ileum
- c) SES-CD-inflammatory surface in a large area but without ulcerations
- d) SES-CD-Stenosis 3: no endoscopic passage possible
Table 2: “Rutgeerts Score” for postoperative assessment (likelihood of relapse) in CD (5,6).
|¡1||<5 aphthous lesions in the neoterminal ileum|
|¡2||>5 anastomotic lesions with passable stenosis (skip lesions); or lesions in the area of the anastomosis|
|¡4||diffuse ileitis with deep ulcerations and/or Stenosis|
Fig. 2: Rutgeerts Score.
- a) i1: <5 aphthous lesions in the neoterminal ileum
- b) i2: anastomotic lesions with passable stenosis
- c) i3: diffuse ileitis
- d) i4: diffuse ileitis with deep ulcerations
Endoscopic Scores – Ulcerative ColitisSeveral scores are available for endoscopic assessment of disease activity in UC. The most relevant scores, “Ulcerative Colitis Endoscopic Index of Severity” (UCEIS), Baron Score and Mayo Score, are detailed in the following. For studies in particular, the UCEIS is the score that has been validated most and has reached the best correlation with clinical symptoms and could be used for further disease prediction. Vascular pattern, bleeding and erosions/ulcerations are scored (Table 3) (7); however, the unclear differentiation between erosion and superficial ulceration has been criticized with the UCEIS score.
Table 3: “Ulcerative Colitis Endoscopic Index of Severity” (UCEIS) (7).
|Category (the most serious change is evaluated)||Definition (Likert Scale)|
|Vessels||1 = normal 2 = partial loss 3 = total loss|
|Bleeding||1 = none 2 = mucosal 3 = luminal bleeding (mild) 4 = luminal bleeding (severe)|
|Erosions/ulcerations||1 = none 2 = erosion 3 = superficial ulcerations 4 = deep ulcerations|
Fig. 3: UCEIS.
- a) partial loss of vessels
- b) luminal bleeding, mild
- c) luminal bleeding, severe
- d) superficial ulcerations
- e) deep ulcerations
Table 4: “Mayo Score” (9)
|Stool frequency (above average)||0||1 – 2||3 – 4||>5|
|Overall physician assessment||normal||mild||moderate||severe|
|Daily activities||normal||slightly restricted||significantly restricted||massively restricted|
Fig. 4: Endoscopic Subscore, Mayo Score.
- a) inactive
- b) mild
- c) moderate
- d) severe
Table 5: “PICaSSO-Score” (10).
|Mucosal changes||none||Microerosions/ abscesses||Erosions < 5mm||Erosions > 5mm|
|Vascular changes||Non-dilated vessels/td>||Dilated vessels||Intramucosal bleeding||Luminal bleeding|
Fig. 5: Not included in scores:
- a) villous colonic changes
- b) pseudopolyps
- c) extensive colonic atrophy
- d) Colon with multiple visible scars
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